Medical care costs and quality are a serious problem facing America as well as other developed countries. Globally, costs are rising rapidly. About 80-90% of health care costs is for clinical services. It is widely documented, in reports such as Crossing the Quality Chasm (IOM, 2001), that these services, in virtually all countries, are inefficient, frequently unsafe, often not appropriate, and regularly not delivering services that have been shown to improve health. Estimates by experts suggest that upwards of 30% of the cost of clinical care is wasted on unnecessary and inefficient care.
This poor care is deeply imbedded in American health care delivery and financing methods. Many have said that our health care is a village industry and that industrial types of solutions might help better manage the transactions that constitute medical care.
There is a significant opportunity for improvement through rationalizing the process flow typical of medical care (we will call this the medical “supply chain”)—with the patient usually moving from least to most technically complex care. These transactions for every patient with an episode of illness, and ultimately a single diagnosis, are currently unmanaged and poorly integrated and coordinated. The looseness of this process results in errors, omissions, missing information, duplication, re-work, inefficiency, sub-optimal quality, poor service, and high cost.
Many attempts have been made in the past to improve pieces or parts of the medical supply chain. These have ranged from utilization management—in which clinicians are asked to justify the appropriateness of their actions and to receive approval from the insurer—to putting large financial incentives in the hands of primary care doctors to manage care (so-called gate-keeping). While each of these appears to have some effect on reducing costs, concerns about quality, withholding of care, and double agent behavior of doctors have largely blocked these approaches. Utilization management, pre-authorization, and gate-keeping for pay have been waning and, as they have done so, medical costs have resumed an upward trajectory of 8-10% per year after five years of stability in the 1990's.
The use of expert guidelines is one approach that has been proposed to improve decision-making in health care. Expert guidelines are widely available commercially and publicly, and many sources exist for updating and publishing them to doctors in paper or electronic form. It has been claimed that new inventions in branching electronic decision support systems can guide and monitor the decisions that doctors make. Examples of such systems are discussed in, for instance, U.S. Pat. No. 5,953,704, to McElroy, et al., U.S. Pat. No. 6,049,794, to Jacobs, et al., U.S. Pat. No. 6,353,817, to Jacobs, et al, and U.S. Pat. No. 5,517,405, to McAndrew, et al.
Studies have shown, however, that such guidelines are rarely utilized by doctors and therefore have not had much impact on improving care. See, e.g., Effective Health Care: NHS Centre for Reviews and Dissemination. 5:1. February, 1999. ISSN:0965-0288; Davis D, Thomson M A, Oxman A D et al. Translating Guidelines into Practice. CMAJ. 1997; 157:408-16; Wensing M, Van der Weijden T R G. Implementing Guidelines And Innovations In General Practice. Br J Gen Pract 1998;48:991-7. In short, these guidelines have not been easily incorporated into the daily work of doctors so that they are feasible to use at the point of care and in the process of care. Most such systems provide so much information and are so complicated that doctors do not use them.
Other approaches to manage care have depended on electronic medical records (EMR), suggesting that these will provide the basis for documenting and structuring medical care. Electronic reminders and electronic prescription writing are good examples of an EMR approach to support good practice. However, electronic medical records have been resisted by most doctors and are in place in only four percent of medical practices in the U.S. These installations are largely in hospitals, and occasionally very large group practices. Therefore, few practices where decision tools are needed for support and integration of care actually employ a comprehensive EMR. Because of the high operating cost in time and money, many feel that comprehensive EMRs will be long in coming to office practice.
One of the primary problems with existing decision support tools is that they fail to adequately recognize and respond to how doctors actually do their work. Doctors are time constrained and practical. Any electronic support system should be easy to use in the workflow at the point of care and, so far, none of the present designs are. Moreover, an electronic support tool must deal with the true nature of the medical supply claim i.e.—that the process of care constitutes a series of linked handoffs, not independent acts taken separately by different doctors. Serious medical problems are managed as a series of integrated transitions and transactions, usually starting with a referral by a general practitioner or primary care clinician into the specialist and hospital sector. This train of events proceeds for an individual patient's episode of care for a condition, by a referral to a specialist based on the referring doctor's best diagnosis, then to increasingly specialized doctors for further opinions and study, and then often ends with a specialist delivering a complex diagnostic and treatment regimen, even surgery, to attempt to treat the problem. Each step is an input to the progression of care for what is usually a single problem and its ultimate resolution that “closes the case” on the episode. This constitutes the “supply chain” in medical care. Each step of the process is an input to the next. If done well, each step and handoff is appropriate and efficient, adds value, and contributes to the overall result. Done poorly, and the care suffers.
The time pressures of doctors and the disintegration of the work of doctors from one another makes designing a practical support system difficult. Typical guideline decision support tools are complicated and require considerable time to use. They often function more like textbooks than as a simple process support tool. Moreover, there is no system that supports, coordinates, and tracks the supply chain and links together care decisions, documentation, monitoring and feedback as the patient's care progresses.